Management of Acute Urinary Tract Infections in Infants

New guidelines discussed at AAP 2012 cover assessment, diagnosis, and treatment of urinary tract infections in children up to two years of age.

Robert D. Fildes, MD, discussed guidelines for the diagnosis and management of urinary tract infections (UTI) at the 2012 American Academy of Pediatrics Convention, in New ORleans, LA, the first such update from the AAP since 1999.

Fildes is a practicing pediatric nephrologist and the Medical Director at the Pediatric Kidney Center, Inova Fairfax Hospital, in Fairfax, VA. Dr. Fildes praised the “very worthy effort” made by the new guidelines’ framers. He noted, “these guidelines were never intended to be used in a court of law to determine fault… their intent was to give a structure in which to practice sensible evidence based medicine. They are based on the current data available, which have limitations.”

Fildes emphasized that these findings are not intended for children less than two months of age or greater than two years of age, children with neurologic or anatomic abnormalities, or for children with afebrile UTIs. The recommendations include seven action statements, three for urinary tract infection diagnosis and four for management, each with a level of recommendation.

Action Statement 1 (evidence quality A; strong recommendation): Clinicians should obtain a urine specimen for urine culture and urinalysis before an antimicrobial agent is given. The specimen must be obtained through catheterization or suprapubic aspiration, not through culture of urine collected in a bag, due to high rate of false positives.

Action Statement 2 (evidence quality A; strong recommendation): A febrile infant with no apparent fever source should be assessed for the likelihood of UTI. If the febrile infant has low likelihood, clinical follow-up without testing is sufficient. If a febrile infant is not in a low risk group the clinician may either obtain urine specimen for culture and urinalysis or perform urinalysis only. If urinalysis suggests a UTI, urine specimen should be obtained through catheterization or SPA and cultured; if negative, one should monitor the clinical course.

Action Statement 3 (evidence quality C; recommendation): For UTI diagnosis, urinalysis results should suggest both infection and 50,000 colony-forming units/ml (CFUs) or uropathogen cultured through catheterization or suprapubic aspiration. This recommendation differs from the 1999 guidelines. Fildes stated that he personally “would probably assume a child had a UTI if he had only 20,000 CFUs but met other criteria for a UTI.”

Action Statement 4a (evidence quality: A; strong recommendation): Clinicians should base the choice of administration route on practical considerations, and the choice of agent on local microbial sensitivity, adjusting after testing of isolated pathogen. 4b (evidence quality: B; recommendation): Duration of antimicrobial therapy should be 7-14 days.

Action Statement 5 (evidence quality C; recommendation): Febrile infants with UTIs should undergo renal and bladder ultrasonography.

Action Statement 6 (evidence quality B; recommendation): Voiding cystourethrogram (VCUG) should not be performed after the first febrile UTI but is indicated if renal bladder ultrasound (RBUS) reveals findings suggesting high-grade vesicoureteral reflux VUR or obstructive uropathy. “It was action statement 6 that started the controversy with the American Urological Association [regarding the lack of endorsement of the VCUG].” Fildes noted that the two sides disagree about the data quality and methodology of the studies used to make the recommendation. These studies were not randomized clinical trials, but these studies are now underway. “Antibiotic prophylaxis may or may not be beneficial in lower grade VUR,” Fildes remarked, “but knowing about the presence of VUR may still be important.”

Action Statement 7 (evidence quality: C; recommendation): After UTI, the clinician should instruct parents to seek prompt medical attention for future febrile illnesses, to ensure proper detection and treatment of recurrent infections.

Fidles said that clinicians can expect updated guidelines from the AAP in the next five years, based on new data coming in.